www.sinagroup.org the saudi initiative for asthma on behalf of the sina group mohamed s. al-moamary,...
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The Saudi Initiative for Asthma
On behalf of the SINA groupMohamed S. Al-Moamary, FRCP (Edin) FCCP
King Abdulaziz Medical City-Riyadh
King Saud bin Abdulaziz Uinversity for Health Scinces
June 2010
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Asthma Diagnosis & Management
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SINA is developed by a task force originated from the Saudi Initiative for Asthma Group under the umbrella of the Saudi Thoracic Society
SINA is a practical approach for a comprehensive management of asthma in adults and children and when to refer to a specialist.
International recommendations were customized to the local setting for asthma diagnosis and management
Directed to HCW dealing with asthma who are not specialists in the field.
What is SINA?
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Purpose of SINA
To provide a document that is easy to follow, simple to understand yet totally updated and carefully prepared for use by non-asthma specialist including primary care doctors and general practice physicians
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Where do you find SINA?
The SINA guideline was published in the Annals of Thoracic Medicine:
Al-Moamary MS, Al-Hajjaj MS, Idrees MM, Zeitouni MO, Alanezi MO, Al-Jahdali HH, Al Dabbagh M. The Saudi Initiative for asthma. Ann Thorac Med 2009;4:216-33
(www.thoracicmedicine.org):
The SINA guidelines booklet is available at: www.sinagroup.org
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Saudi Thoracic Society commitment
The STS is committed to improve the care of asthma by a long term plan:
Periodic scientific meetings
Annual asthma meeting (since 2001)
Frequent asthma courses
Educational brochures
Publishing new and updated asthma guidelines
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SINA Task Force
Mohamed S. Al-Moamary (Head), College of Medicine, King Saud bin Abdulaziz University for Health Sciences, Riyadh
Mohamed S. Al-Hajjaj, College of Medicine, King Saud University, Riyadh
Majdy M. Idrees, Military Hospital, Riyadh
Mohamed O. Zeitouni, King Faisal Specialist Hospital and Research Center, Riyadh
Mohammed O. Alanezi, College of Medicine, King Saud bin Abdulaziz University for Health Sciences, Riyadh
Hamdan H. Al-Jahdali, College of Medicine, King Saud bin Abdulaziz University for Health Sciences, Riyadh
Maha M. Al Dabbagh, King Fahd Armed Forces Hospital, Jeddah
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Acknowledgment
The Saudi Initiative for Asthma group would like to thank the following reviewers :
• Prof. Eric Bateman from the University of Cape Town Lung Institute, Cape Town, South Africa
• Prof. J. Mark FitzGerald from the University of British Columbia, Vancouver, BC, Canada
• Prof. Ronald Olivenstein from the Meakins-Christie Laboratories and the Montreal Chest Research Institute, Royal Victoria Hospital, McGill University, Montreal, Quebec, Canada.
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SINA Documents
Published manuscript
Booklet
Electronic version
Slides kit
Flyers
Website: www.sinagroup.org
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Sections of SINA
Epidemiology
Pathophysiology
Diagnosis
Medications
Approach to Management
Treatment Steps
Special Situations
Acute Asthma
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Prevalence
Prevalence of asthma has increased between 1986 – 1995
Alfrayyah et al. Ann Allergy Asthma Immunol 2001;86:292–296
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Burden of Asthma
Asthma is among the most common chronic illnesses in Saudi Arabia53% had missed school or work (AIRKSA-2007)
35% attempted Unconventional therapy (Al Moamary, ATM 2008)
46% were controlled in Riyadh (AIRKSA-2007) 36% were controlled in 5 tertiary care centers in Riyadh (Aljahdali SMJ-2008)
48% were controlled in one center (Al Moamary, ATM 2008)
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AIRKSA report (Ministry of Health)
78 % of adults & 84% of kids reported acute asthma over 12 months (AIRKSA)
54 % of adults & 80% of kids reported ER over 12 months (AIRKSA)
45-68% of adults & 37-56% of kids reported limitation of activity over 12 months (AIRKSA)
76 % of adults & 78% of kids never had spirometry(AIRKSA)
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Pattern of asthma treatment
Ann Thorac Med 2006;1:20-5
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Pathology of Asthma
Inflammation
Airway Hyper-responsiveness Airway Obstruction
Symptoms of Asthma
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Pathophysiology
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Inflammation Remodeling
Inflammation
Airway Hypersecretion
Subepithelial fibrosis
Angiogenesis
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Diagnosis - History
Episodic attacks:
Cough
Breathlessness
Wheezing
Nocturnal symptoms
Patient could be asymptomatic between attacks
co-existent conditions: GERD, rhinosinusitis.
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Relevant Questions
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Normal between attacks Bilateral expiratory wheezingExamination of the upper airways Other allergic manifestations: e.g., atopic dermatitis/eczema Consider alternative Dx when there is localized wheeze, crackles, stridor, clubbing
Physical Examination
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Investigations
Measurements of lung function:
Spirometry
Peak expiratory flow (PEF)
Normal Spirometry does not role out asthma
Spirometry is superior to PEF
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Bronchodilator response
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Measurements of allergic status to identify risk factors (if indicated)Chest X-ray is not routinely recommendedRoutine blood tests are not routinely recommendedIgE measurement is indicated in severe cases
Clinical Assessment
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Level of Control: Level of Control:
• Control: 20-24
• Partial control: 16-19
• Uncontrolled: < 16
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Differential Diagnosis
Upper airway diseasesAllergic rhinitis and sinusitis
Obstructions involving large airwaysForeign body in trachea or bronchusVocal cord dysfunctionVascular rings or laryngeal websLaryngotracheomalacia, tracheal stenosis, or bronchostenosisEnlarged lymph nodes or tumor
Obstructions involving small airwaysViral bronchiolitis or obliterative bronchiolitisCystic fibrosisBronchopulmonary dysplasiaHeart disease
Other causesRecurrent cough not due to asthmaAspiration from swallowing mechanism dysfunction or GERD
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Differential Diagnosis
COPD (e.g., chronic bronchitis or emphysema)
Congestive heart failure
Pulmonary embolism
Mechanical obstruction of the airways (benign and malignant tumors)
Pulmonary infiltration with eosinophilia
Cough secondary to drugs (e.g., angiotensin-converting enzyme (ACE) inhibitors)
Vocal cord dysfunction
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Asthma in children < 5 years
The diagnosis is challenging
Asthma must be distinguished from other causes of persistent and recurrent wheezing
The earlier the onset of a wheeze, the better the prognosis
A family history of atopy and asthma and maternal atopy are strongly associated with persistent childhood asthma
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Asthma in children < 5 years
Three categories of wheezing:Transient early wheezing:
It outgrown in the first three years
It associated with prematurity and parental smoking.
Persistent early-onset wheezing: Symptoms continue beyond the age of six
Associated with acute viral respiratory infections and have no evidence of atopy
Late-onset wheezing/asthma:Symptoms persist into childhood and adult life.
Atopic background, often with eczema
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Asthma in children < 5 years
No tests can diagnose asthma with certainty.
Lung function testing is not very helpful
CXR may help to exclude structural abnormalities of the airway.
A trial of treatment with short-acting bronchodilators and inhaled corticosteroids (ICS) for at least 8 to 12 weeks may provide some guidance as to the presence of asthma.
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Management
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Patient/Dr Partnership
Enhance the chance of disease control
Agreed goals of management
Guided self-management plan
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Asthma Education
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Non-Adherence
Drugs:Poor technique of inhaler devices.Regimen with multiple drugs.Occurrence of Side effects from the drugs.Cost of medications.
Non-drugsLack of knowledge about asthma.Lack of partnership in the management.Inappropriate expectations.Underestimation of severity.Cultural issues.
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Precipitating Factors
Indoor Allergens and Air Pollutants
Outdoor Allergens
Occupational Exposure
Food and Drugs
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إتخاذه : الواجب اإلجراء الهوائية للشعب الموسع البخاخ كل ___إستخدام ____بخة
ساعات . عاجلة بصفة الطبية اإلستشارة طلب الواقي البخاخ جرعة a (____بخة ______إلى(____زيادة يوميا مرة
يلي :10لمدة ما عمل السابقة الجرعة إلى الرجوع ثم أيام
الحادة - 3 المتأزمة المساعدة) الحالة بطلب سارعلما الطبية( استجابة تحدث لم إذا
حدث : أو سبق. الربو أزمة أعراض زيادة. واحد نفس في كلمتين إتمام على القدرة عدم إستخدام من ساعة نصف من أقل بعد الربو أعراض عودة
الهوائية . للشعب الموسع البخاخ أقل الهواء نفخ على الطبيعي% .50القدرة الحد من
إتخاذه الواجب : اإلجراء الواقي البخاخ جرعة لمدة _____بخة ______إلى ______زيادة a يوميا مرة
السابقة 10 الجرعة إلى الرجوع ثم أيام الهوائية للشعب الموسع البخاخ ) إستخدام
كل ( ( ) لمدة ____ بخة بإنتظام تتحسن _____ساعات حتى أو أيامالحالة
. ممكن وقت أقرب في الطبيب إستشارة
على - ) 2 ربو أزمة اإلستقرار المتوسطة الحالة: ) الحدوث وشك
من أكثر الهوائية للشعب الموسع البخاخ مرات 3إستخدام. a يوميا
بسبب الليل في ( اإلستيقاظ الصدر) في صفير ، كتمة ، كحة. فيروسية برد نزلة أعراض وجود بين الهواء نفخ على الطبيعي % .80 – 60القدرة الحد من
إتباعه : الواجب األدوية اإلجراء على اإلستمرار: المعطاة
الهوائية للشعب الموسع البخاخ كل _____ إستخدام عند ____بخة ساعاتب ارياضية التمارين وقبل دقيقة .30 – 15الضرورة
الواقي البخاخ لمدة ______بخة _____إستخدام منتظم بشكل و a يوميا مرة أخرى : أدوية ( . )
المستقرة- :1 الحالة ) دراسة ) ، نوم ، لعب طبيعي بشكل الحياة ممارسة. الليل في الربو أعراض إختفاء الهوائية للشعب الموسع في البخاخ إستخدام من) ندرة 3أقل
) a أسبوعيا مرات من أكثر الهواء تدفق الطبيعي% 80سرعة الحد من
حالته حسب المختص الطبيب إشراف تحت توضع به خاصة ذاتية عالجية خطة مريض لكل
Self-management plan
. a فورا الطوارئ لقسم التوجه من البد) اإلسعاف) أطلب أو للطوارئ أزمة :توجه تدهورت إذا
فياألطراف إزرقاق حدث أو ، السابقة اإلجراءات من الرغم على الربومن ألقل الهواء تدفق سرعة في تدني أو ، الوعى مستوى في تدهور أو
الطبيعي % 50 المعدل من
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Asthma Medications
Controllers are medications taken daily on a long-term basis to keep asthma under clinical control chiefly through their anti-inflammatory effects.Relievers are medications used on an as-needed basis that act quickly to reversebronchoconstriction and relieve symptoms.
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Controller Medications
Inhaled glucocorticosteroids
Leukotriene modifiers
Long-acting inhaled B2-agonists
Theophylline
Anti-IgE
Systemic glucocorticosteroids
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Inhaled Corticosteroids
The most effective antiinflammatory medications for the treatment of asthma
Benefits of ICS:
Reduce symptoms:improve quality of life
improve lung function
decrease airway hyperresponsiveness
control airway inflammation
reduce frequency and severity of exacerbations, and reduce mortality.
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Inhaled Corticosteroids
When ICS discontinued, deterioration of clinical control follows within weeks to months in most patients
Most of the benefits from ICS are achieved in adults at relatively low doses
Increasing to higher doses may provide further benefits in terms of asthma control but increases the risk of side effects
Tobacco smoking reduces the responsiveness to ICS
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Inhaled Corticosteroids
To reach control, add-on therapy with another class of controller is preferred to increasing the dose of ICS
ICS are generally safe and well-tolerated
Though low-medium dose of ICS may affect growth velocity, this effect is clinically insignificant and may be reversible.
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Inhaled Corticosteroids
Local adverse effects:oropharyngeal candidiasis
Dysphonia – may be e reduced by using MDI + spacer devices and mouth washing
Systemic side effects are occasionally reported with high doses and long-term treatment
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Inhaled Corticosteroids
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Leukotriene modifiers (LTRA)
LTRA reduce airway inflammation and improve asthma symptoms and lung function but with a less consistent effect on exacerbations, especially when compared to ICS.
Alternative treatment to ICS for patients with mild asthma, especially in those who have clinical rhinitis
Some patients with aspirin-sensitive asthma respond well to the LTRA
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Leukotriene modifiers (LTRA)
Available as Montelokast in Saudi Arabia
Their effects are generally less than that of low dose ICS
When added to ICS, LTRA may reduce the dose of ICS required by patients with uncontrolled asthma, and may improve asthma control
LTRA are generally well-tolerated. There is no clinical data to support their use under the age of six months.
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LABA
LABA: (formoterol and salmeterol)
Should not be used as monotherapy
Combination with ICS lead to: improves symptoms
decreases nocturnal asthma
improves lung function
decreases the use rapid-onset inhaled B2-agonists
reduces the number of exacerbations
achieves clinical control of asthma in more patients, more rapidly, and at a lower dose of ICS
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Combination devices
Sympicort turbohaler: Budesonide/Formeterol: 160/4.5
Seretide:Fluticasone/Salmeterol
Evohaler: 50/8 125/8 250/8
Diskus: 100/16 250/16 500/16
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Theophylline
Weak bronchodilator with modest anti-inflammatory properties.
It may provide benefit as add-on therapy in patients who do not achieve control on ICS alone
Less effective than LABA and LTR.
Side effects: gastrointestinal symptoms
cardiac arrhythmias
seizures, and even death
Drug interaction
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Anti-IgE
Omalizumab (Xolair) indication: Uncontrolled severe allergic asthma on high dose ICS and other controllers.
Needs specialist consultation.
Side effects: Pain and bruising at injection site and very rarely anaphylaxis (0.1%).
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Oral glucocorticosteroids
Long-term oral glucocorticosteroid therapy may be required for uncontrolled asthma despite maximum standard therapy. It is limited by the risk of significant adverse effects. Side effects:
Osteoporosis, hypertension, diabetes, adrenal insufficiency, obesity, cataracts, glaucoma, skin thinning, and muscle weakness. Withdrawal can elicit adrenal failure. In patients prescribed long-term systemic glucocorticosteroids, prophylactic treatment for osteoporosis should be considered.
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Reliever Medications
Short-acting inhaled B2-agonists
Anticholinergics
Theophylline
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Short-acting B2-agonists
The medications of choice for symptoms relief
Pretreatment for exercise-induced bronchoconstriction.
Formoterol is used for symptom relief because of its rapid onset of action.
Increased use, especially daily use, is a warning of deterioration of asthma control
Side effects: B2-agonists are associated with adverse systemic effects such as tremor and tachycardia.
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Anticholinergics
Less effective than SABA.
Used in combination in acute asthma.
An alternative bronchodilator for patients with adverse effects from rapid acting B2agonists.
Side effects: can cause a dryness of the mouth and a bitter taste.
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Asthma control
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Principles of management
1. Initiation
2. Adjustment
3. Maintenance
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Initiation of treatment
Step 1 SABA on as needed bases
Step 2 For patients who are not currently taking long-term controller medications.
Step 3 If the initial symptoms are more frequent.
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Initiation of treatment based on Asthma Control Test
The consensus among SINA panel is to simplify the approach to initiate asthma therapy by using ACT
ACT Score ≥ 20 Step 1
ACT Score 16–19 Step 2
ACT Score 16 Step 3
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Adults Patients with Asthma
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Children with Asthma
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Assessment of Asthma Control
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Approach to Asthma Treatment in Adults
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Approach to Asthma Treatment in Children
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Principles of Asthma Treatment
Daily long-term controller medication is needed
ICS are considered as the most effective controller
Relievers or rescue medications must be available to all patients at any step
SABA or rapid onset LABA should be taken as needed to relieve symptoms
Increasing use of reliever treatment is usually an early sign of worsening asthma control
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Principles of Asthma Treatment
Treat patients who may have seasonal asthma as having uncontrolled asthma during the season at step 1 for the rest of the year
Patients who had two or more exacerbations requiring oral corticosteroids or hospital admissions in the past year should be treated as patients with uncontrolled asthma, even if the level of control seems good in between the exacerbations
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Step 1 - Recommendations
The symptoms are usually mild and infrequent
If patient may experience sudden, severe, and life-threatening exacerbations, treat these exacerbations accordingly
Consider rapid onset B2-agonist to be taken “as needed” to treat symptoms
If B2-agonist use increases to more than two days a week, treate as partially controlled asthma
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Step 2 - Recommendations
The preferred recommendation is daily ICS at a low dose (< 500 μg of beclomethasone equivalent/day
Alternative treatments include LTRA (montelukast)
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Step 3 – Recommendations
Add a LABA to a low-medium dose ICS for patients whose asthma is not controlled on a low dose ICS alone, such as:
Fluticasone/Salmeterol (Seretide)
Budesonide/Formoterol (Symbicort)
Use a maintenance dose of the combination drugs twice daily
Use the rapid onset B2-agonist as a reliever treatment (Evidence A).[129]
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Step 3 - S.M.A.R.T® approach
S.M.A.R.T® approach: Use of Formoterol/Budesonide for both rescue and maintenance
Maintenance dose single inhaler (1–2 puff 160/4.5 BID) is selected plus extra puffs from the same inhaler up to a total of 12 puffs per day.
Those patients who require such high dose should seek medical advice to step up therapy that may include use of short course of oral prednisone.
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Step 3 - GOAL study
GOAL study has shown that an escalating dose of combination of Fluticasone/ Salmeterol (Seretide) achieves
Well controlled asthma in 85% of patients
Totally controlled asthma in 30% of patients
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Step 3 – Alternative therapy
Increasing the dose ICS to the medium to high dose range as a monotherapy
Adding LTRA to a low-medium dose ICS, especially with concomitant rhinitis
Adding sustained release theophylline to a low-medium dose ICS
Consultation with a specialist is recommended for patients whenever there is a difficulty in achieving control
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Step 4 – Recommendations
Maximizing treatment is recommended by combining high-dose ICS with LABA
Adding LTRA or theophylline to high-dose ICS and LABA should be considered
Omalizumab may be considered:Allergic asthma (as determined by skin test or RAST study) and still uncontrolled.
Special knowledge about the drug
Consultation is recommended
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Step 5 - Recommendations
Omalizumab to be considered for patients who have allergic asthma and persistent symptoms despite the maximum therapy mentioned above
lowest possible dose of long-term oral corticosteroids for patient who:
Does not have allergic asthma
Omalizumab is not available or not adequately controlling the disease
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Step 5 – long term steroids
Long-term systemic corticosteroids:lowest possible dose to maintain control
Monitor for the development of side effects
Continue attempts to reduce the dose
Maintaining high-dose of ICS therapy
Strongly consider concurrent treatments with calcium supplements and vitamin D
Consultation is mandatory
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Asthma Control for Children
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Children younger than 5 years
The most effective bronchodilator available is SABA
If control is not achieved and controller treatment commenced, the lowest dose of ICS delivered by MDI and a spacer
LTRA is considered as an alternative therapy especially when there is concomitant rhino-sinusitis.
Doubling the dose of ICS If asthma control is not achieved on low dose ICS
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Children younger than 5 years
If asthma is not controlled, increase ICS dose to the maximum, and/or adding a LTRA or theophylline
Low dose of oral corticosteroids for a few weeks should be limited to severe uncontrolled cases
Seasonal symptoms: discontinue daily controller therapy after the season
Frequent episodes by severe viral infection may justify a trial of ICS
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Maintaining Control
Regular follow-up is essential
Follow-up at 1- to 6- month intervals is recommended, depending on the level of control
Consider 3- month intervals, if a step down in therapy is anticipated.
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Allergen Immunotherapy (AIT)
gradual immunization by increasing doses of standardized allergen responsible for causing allergic symptoms either subcutaneously or sublingually
This will induce increased tolerance to the allergen that may provide long-term relief of symptoms during subsequent exposure to the same allergen
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Allergen Immunotherapy (AIT)
AIT is more effective in seasonal asthma than in perennial asthma particularly when used against a single allergen
AIT may be considered if strict environmental avoidance and pharmacologic intervention have failed to control asthma
Side effects include systemic allergic reactions, occasional anaphylaxis and, even, rare fatalities
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Special Situations
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Asthma and pregnancy
Present in up to 8% of pregnant women.
Unpredictable course: one third will have worsening of their of asthma control
Maintaining adequate control of asthma during pregnancy is essential for the health and well-being of both the mother and her baby.
Identifying and avoiding triggering factors should be the first step of therapy for asthma during pregnancy
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Asthma and pregnancy
Same stepwise approach as in the nonpregnant patient.
Salbutamol is the preferred SABA
ICSs are the preferred controllers
Use of ICS, theophylline, antihistamines, B2-agonists, and LTRA is generally safe
Acute exacerbations of asthma during pregnancy should be treated on the same outlines as in nonpregnant patients
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Cough-variant asthma
Cough is the main symptom
It is common in children, and is often more problematic at night
Other diagnoses to be considered are:Drug-induced cough caused by angiotensin-converting-enzyme inhibitors
GERD
Postnasal drip and chronic sinusitis
Treatment is similar to long-term management of asthma
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Exercise-induced Asthma
Bronchoconstriction peaks within 10 to 15 minutes after completing the exercise and resolves within 60 minutes.
Prevention: SABA before exercise
Warm-up period before exercise
Some patients may need maintenance therapy
Regular use of LTRA may help in this condition especially in children
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Aspirin/NSAID induced Asthma
Occurs in 10–20% of adults with asthma
The majority experience first symptoms during the third to fourth decade.
Once aspirin or NSAID hypersensitivity develops, it is present for life.
Within 1-2 hours following ingestion of aspirin, an acute, severe attack develops, and is usually accompanied by rhinorrhea, nasal obstruction, conjunctival irritation, and scarlet flush of the head and neck
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Aspirin/NSAID induced Asthma
Prevention by avoidance of aspirin/NSAID
Patients for whom aspirin is considered essential, they should be referred to an allergy specialist for aspirin desensitization
Aspirin and NSAID can be used in asthmatic patients who do not have aspirin induced asthma
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GERD triggered asthma
GERD is more prevalent in asthmatics
Mechanisms of GERD triggered asthma:vagal mediated reflex
reflux of micro-aspiration of gastric contents into the upper airways
If GERD symptoms presents, a trial of GERD therapy for 6–12 weeks and lifestyle modifications may be considered
Asymptomatic patients with uncontrolled asthma may not benefit from GERD therapy
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Management of Acute Asthma
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Management of Acute Asthma
Mortality reported in patients who have received inadequate treatment or poor education
The following should be carefully checked: Previous history of near fatal asthma
Patient on three or more medications
Heavy use of SABA
Repeated visits to emergency department
Brittle asthma
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Severity of acute asthma
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Initial Management of Acute Asthma
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Oxygen
High concentration of inspired oxygen should be used to correct hypoxemia
Pulse oximetry should be used to tailor oxygen therapy
Failure to achieve oxygen saturations of more than 92% is a good predictor of the need for hospitalization
Normal or high PaCO2 is an indication of a severe attack, and the need for specialist consultation
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Bronchodilators
Inhaled salbutamol is the preferred choice
Repeated doses should be given at 15–30 minute intervals.
Alternatively, continuous nebulization (Salbutamol at 5–10 mg/hour) may be used for one hour if there is an inadequate response to initial treatment.
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Bronchodilators
In patients who are able to use the inhaler devices, 6–12 puffs of MDI with a spacer are equivalent to 2.5 mg of Salbutamol by nebulizer
In moderate to severe acute asthma, combining ipratropium bromide with Salbutamol has some additional bronchodilation effects, in reducing hospitalizations and greater improvement in PEF or FEV1
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Steroid therapy
Systemic steroids: reduce relapses and subsequent hospital admission
Oral steroid = injected steroids
Oral prednisolone: 40–60 mg daily
Parenteral steroids:Hydrocortisone: 300–400 mg/day
Methylprednisolone: 60–80 mg/day
Systemic steroids should be given for seven days for adults and three to five days for
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Magnesium sulphate
A single dose of IV magnesium sulphate (1.2–2 gm IV infusion over 20 mins) is safe and effective
Routine use of IV magnesium sulphate in patients with acute asthma presenting to emergency department is not recommended.
Its use should be limited to those with sever exacerbation who fail to respond to treatment after an hour
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Intravenous aminophylline
In acute asthma, the use of intravenous aminophylline did not result in any additional bronchodilation compared to standard care with B2-agonists
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Antibiotics
Viral infection is the usual cause of asthma exacerbation
The role of bacterial infection has been probably overestimated, and routine use of antibiotics is strongly discouraged
They should be used when there is associated pneumonia or bacterial bronchitis
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Referral to a specialist center
Status asthmatics
Deteriorating PEF
Persisting or worsening hypoxia
Hypercapnea, respiratory acidosis (pH <7.3)
Severe exhaustion
Increase work of breathing
Drowsiness
Confusion
Coma
Respiratory arrest
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Criteria for admission
Patients whose peak flow is ≥ 60% best or predicted one hour after initial treatment can be discharged from the emergency department
Criteria for admission: Any feature of a life threatening, near fatal attack
Any feature of a severe attack that persists after initial treatment.
unless any of the following is present:
still suffering from significant symptoms
previous history of near fatal or brittle asthma
concerns about compliance and pregnancy
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Acute asthma in children < 5 years
Early symptoms of an acute exacerbation would usually follow an upper respiratory infection.
Ssymptoms: shortness of breath, wheeze, nocturnal cough, exercise intolerance .
Initiation of treatment: two puffs (200 μg) of salbutamol via spacer is recommended
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Acute asthma in children < 5 years
Immediate medical attention should be taken in case of children less than two year who had a history of poor response to three doses of SABA within 1–2 hours, saturation less than 92%, or the child is acutely distressed.
In this age group, the risk of fatigue, respiratory compromise and dehydration is considerable